Clinical Practice in Rheumatology

120 Pages·2003·6.481 MB·English

by  Maurice Barry MB, FRCPI (auth.)

Maurice Barry
Clinical Practice in
Rheumatology
Foreword by
Professor Michael Doherty
, Springer
Maurice Barry, MB, FRCPI
Consultant Rheumatologist
James Connolly Memorial Hospital
Blanchardstown,
Dublin, Ireland
British Library Cataloguing in Publication Data
Barry, Maurice
Clinic al practice in rheumatology
1. Rheumatology
1. Title
616.7'23
ISBN 978-1-85233-719-3 ISBN 978-0-85729-430-2 (eBook)
DOI 10.1007/978-0-85729-430-2
American Library of Congress Cataloging-in-Publication Data
A Catalog record for this book is available from the Library of Congress
ISBN 978-1-85233-719-3
Apart from any fair dealing for the purposes of research or private study, or
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1988, this publication may only be reproduced, stored or transmitted, in any
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duction outside those terms should be sent to the publishers.
© Springer-Verlag London 2003
Originally published by Springer-Verlag London Limited in 2003
2nd printing 2004
The use of registered names, trademarks, etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from
the relevant laws and regulations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug
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the respective user must check its accuracy by consulting other pharmaceutical
literat ure.
Typeset by Florence Production Ltd, Stoodleigh, Devon, England
28/3830-54321 Printed on acid-free paper SPIN 10993811
Dedication
To the patients and staffofthe Department
ofRheumatology, Blanchardstown Hospital,
and to Rosie, Rory, Kate and Stevie.
Preface
Rheumatology is predominantly aclinic-based speciality. The medical staff
in the clinic often includes doctors in their early postgraduate years who
rotate through the specialtyeveryfew months.Theyusuallyarrive knowing
less about the basics of rheumatology than other specialties, but rapidly
need to learn what to ask or do next with the patient sitting in front of
them. The book is aimed at this group. It will also be ofbenefit to trainees
in general (internal) medicineandgeneralorfamilypractice,and to medical
students, rheumatology nurse specialists and allied health professionals. A
further aim in writing this book is to reduce the time busy departments
need to spend inducting new medical staffevery few months.
Wehavetriedtoincludethecurricularrequirementinrheumatologylikely
to be needed for Parts Iand II ofthe Membership in Medicine. Any sugges
tionsfor improvementsthatmightbemade infuture editionsarewelcome.
Maurice Barry
ConsultantRheumatologist,
JamesConnollyMemorial Hospital, Dublin
Acknowledgements
The initial draft of some sections was contributed to by junior doctors
attached to the team. They include Jillian Drury, Mike McWeeney, Liz
Maxwell, Ferga Gleeson and Ai Shiang Bong. Killian O'Rourke and SA
Ramakrishnan wrote a number of sections. I thank them for their major
contribution to what began as guidelines for use in our department.
Thanks to Sara Tubb for typing the manuscript and to Ray Lohan and
Oliver O'Flanagan of the Media Services Department at the Royal College
of Surgeons in Ireland for the clinical photographs. Thanks also to those
patients who allowed themselves be photographed.
The support of Brenda Dooley of Pharmacia and Melissa Morton and
Eva Senior ofSpringer-Verlag London is much appreciated.
v
Theseillustrationsshowthreewomenwithlongstandingsero-positiverheumatoidarthritis.They
illustratetherealityofrecentyearsformanywithrheumatoidarthritis,particularlythosetreated
earlyandappropriately.Notetheabsenceofulnardeviation,swan-neck,Boutonniere,Zthumb
orotherdeformities(permissionsreceived).
vi
Foreword
Locomotor assessment is a required competance ofany doctor due to the
highprevalenceofmusculoskeletalconditions.Thespectrumofthesecondi
tionsrangesfrom relativelyminorself-limitingmechanicalstrainstocomplex
life-threatening multisystem disease.This wide range ofconditions and the
anatomical complexity ofthe system make clinical assessment ofa patient
with musculoskeletal symptoms a daunting challenge for many trainees.
Oftenthechallenge is madegreaterbecauseoflow prioritisation ofmuscu
loskeletal clinical skills teaching in some Medical Schools.
Thisshorthandbook,therefore,isverywelcome.Written byMauriceBarry
aConsultant Rheumatologist in Dublin, it briefly summarises the key prac
tical points relating to the assessment, investigation and management of
patientswith musculoskeletal disease. Itsuncluttered bullet-pointed format
and clarity of style make it a rapid and easy source of clinically relevant
information. Apart from system-specific detail there is an appropriate
emphasis on the wider holistic assessment ofthe individual with musculo
skeletal pain.
This first Edition is fully up-to-date and should prove invaluable to its
target audience of Senior House Officers and Specialist Registrars in
Rheumatology and General Internal Medicine. It is likely to become the
standard Departmental Manual for many UK Rheumatology Units. The
book should also prove useful for a wider range of doctors in Primary
and Secondary Care and for Allied Health Professionals who work in a
Rheumatology MultidisciplinaryTeam.
Michael Doherty
ProfessorofRheumatology
Nottingham UniversityMedicalSchool.
vii
Contents
1 History Taking . 1
New Patients . 1
Extra-articular Symptom Review (Dr K O'Rourke) . 2
2 Locomotor Examination (Dr S A Ramakrishnan) . 3
Range ofMovement (ROM) . 6
3 Common New Presentations . 13
4 Clinic Checklist 17
5 Common Operational Issues . 18
6 Imaging Guidelines . 19
When to Order Plain Radiographs . 19
7 Indices, Instruments, Questionnaires . 21
8 How to Manage Patients . 23
General Guidelines . 23
How Often Should Patients be Reviewed? . 23
Prescriptions . 23
Who to Admit . 23
Blood Forms . 24
When to Seek Advice . 24
The Power ofReassurance . 24
Psychosocial Aspects ofRheumatology . 25
Complementary Treatments . 26
Analgesics . 27
Opioid Analgesics . 27
Non-steroidal Anti-inflammatory Drugs (NSAIDs) . 29
Disease-modifying Drugs (DMARDs) . 30
Methotrexate . 30
Sulfasalazine . 31
ix
x Contents
Hydroxychloroquine (Plaquenil) 32
Azathioprine 32
Gold (Myocrisin) 33
Ciclosporin (Cyclosporin) 34
Cyclophosphamide . . . . . . . . . . . . . . . . . . . . . . . . . .. 35
Newer Agents in Inflammatory Arthritis 36
Leflunomide (Arava) . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Biological Agents .. . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Joint Injections 38
Role ofHealth Professionals 39
Rheumatology Nurse Specialist .. . . . . . . . . . . . . . . .. 39
Physiotherapist 40
Occupational Therapist 41
Rheumatological Disorders
9 Soft Tissue Problems 42
Fibromyalgia Syndrome 42
Neck Pain/Low Back Pain. . . . . . . . . . . . . . . . . . . . . . .. 44
Shoulder Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 48
Carpal Tunnel Syndrome 49
Epicondylitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 50
Bursitis (Dr K O'Rourke) 51
De Quervain's Tenosynovitis. . . . . . . . . . . . . . . . . . . . .. 52
Achilles Tendonitis. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 52
Plantar Fasciitis 53
Benign Hypermobility Syndrome. . . . . . . . . . . . . . . . . .. 53
10 Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 56
Diffuse Idiopathic Skeletal Hyperostosis (DISH) . . . . . . .. 57
11 Rheumatoid Arthritis 58
12 Seronegative Spondylarthropathy . . . . . . . . . . . . . . . . .. 63
Psoriatic Arthritis (Dr KO'Rourke) 64
Ankylosing Spondylitis . . . . . . . . . . . . . . . . . . . . . . . . .. 64
Reactive Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Arthritis Associated with Inflammatory Bowel Disease ... 67
Behc;:et's Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 68
13 Connective Tissue Diseases (CTD) 69
Autoantibodies: A Synopsis . . . . . . . . . . . . . . . . . . . . . . . 69
Raynaud's Phenomenon 71
Systemic Lupus Erythematosus (Dr KO'Rourke) 72
Contents xi
Anti-phospholipid Syndrome (APS) (Dr KO'Rourke) . . .. 75
Mixed Connective Tissue Disease (MCTD) . . . . . . . . . . . . 75
Sjogren's Syndrome 76
Scleroderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Polymyositis/Dermatomyositis 78
Differential Diagnosis ofMuscle Pain and or Weakness . .. 79
Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
14 Infection and Arthritis (Dr S A Ramakrishnan) . . . . . .. 83
15 Pregnancy and Rheumatic Diseases 87
16 Inheritance and Rheumatic Diseases 89
17 Crystal Arthritis 90
Gout 90
Pseudogout 92
18 Polymyalgia Rheumatica (PMR) . . . . .. 93
19 Osteoporosis 95
Acute Vertebral Fracture . . . . . . . . . . . . . . . . . . . . . . . . . 97
20 Paget's Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 98
21 Osteomalacia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 100
22 Uncommon Rheumatological Conditions
(Dr S A Ramakrishnan) . . . . . . . . . . . . . . . . . . . . . . . . .. 102
Reflex Sympathetic Dystrophy (RSD) . . . . . . . . . . . . . . .. 102
Relapsing Polychondritis . . . . . . . . . . . . . . . . . . . . . . . .. 102
Pigmented Villonodular Synovitis (PVNS) 103
Rheumatic Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 103
Adult Onset Still's Disease (AOSD) 104
Sarcoidosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 104
Further Reading 105
Useful Websites 105
Index 107
Note to the Reader
A couple of points are worth emphasising:
• Although we treat some interesting and complex diseases, chronic
musculoskeletal pain is frequently either caused by or exacerbated
by psychosocial distress. Ifyou learn to distinguish the often subtle
differences between organic and non-organic causes of pain and
can deal capably and sensitively with both, you will enjoy the
specialty.
• Be positive with the patient. Making people feel reassured (usually
appropriate irrespective of diagnosis) and engendering a positive
attitude (always appropriate) can be as potent as any drug and
should be appreciated for their true worth.
Before starting the rheumatology rotation you should revise musculo
skeletal anatomy; undergraduate orthopaedic and immunology notes
should also be revisited.
xiii